Journal Club

Benbasset, J and R Baumal. What is Empathy, and How Can It Be Promoted during Clinical Clerkships? Acad Med 2004; 79:832-839.

Reviewed by Sherilyn Smith, MD, University of Washington

This opinion piece is a good review of some of the basic definitions for empathy and how it might be taught and measured. The authors define empathy using a variety of methods and then briefly review the various teaching methods. They also provide evidence that students' empathy decline as they progress throughout their undergraduate training. This finding is the basis for their assertion that the "skill" of empathy should be reinforced in the clinical clerkships. The focus of the author's approach to teach empathy is to reinforce a "patient-centered approach" to interviewing. By adopting a patient-centered approach, students identify patient concerns, and this understanding provides the basis of engagement. Engagement then produces compassion, which leads to the desire to help the patient. The authors go on to outline the basic elements of patient centered interviewing and then target specific behaviors (that are reinforced in the clerkships) that are barriers to empathy (e.g. engagement via patient-centered interviewing): writing up the medical history during the interview, focusing too early on the chief complaint, and performing a complete review of systems.

Overall, the authors give a balanced view of the approach and I enjoyed the overview of patient centered interviewing. This article outlines the tension between competing educational needs. For instance, having students focus on the chief complaint early so they can ask appropriate questions competes with adopting a focus on patient concerns. What I felt was missing were some strategies to resolve these competing agendas. How can I help students adopt a patient-centered interviewing style AND bring the pieces of the patient's story together in order to develop a well integrated assessment and plan? Also missing were outcomes linked to the interventions that demonstrate that the students empathy did not decline following modification of these habits. (Maybe that study is coming!) Finally, the authors did not comment on the important issue of faculty development in this area. If we, the teachers, are unsure about our own educational priorities and what we wish to model (e.g. patient-centered interviewing), we risk paying lip service to an important idea and unknowingly contribute to the decline of empathy in medical students.

(It wasn't surprising to me that empathy declines with time. We see the decline all the time and attribute it to the workload and the need to "detach." It seems to me that by downplaying the importance of empathy we tacitly approve of our superficial approach to patients (and emphasis on disease). I, too, was hoping for some suggestions of things that work. The authors do recommend a single study of an intervention in a clerkship - having a small group of students meet to discuss some of these issues explicitly. The study was published in 1979! What a shame that we haven't built on this. Or have we? Have you tried to introduce some time to address empathy and altruism in your clerkship? Has your intervention worked? Have you disseminated your successes? Karen Marcdante)